QUESTION: My husband has had Parkinson’s for 25 years, severe Alzheimer’s, and other issues. He has taken a severe setback with a recent hospitalization. He is presently very weak, minimally mobile, with very low function cognition. He is now in rehab, but hoping to return home. He is in very rough shape with no human hope of cure or improvement. I am the caregiver for him 24/7 when home. Do I give DNR order? Do I give “no feeding tube” order if that time comes?

ANSWER: First of all, both you and your husband have been through much. My prayer is for both strength and comfort as you face these challenges.

Generally, when addressing the matter of a DNR the first question I ask is “how old is the patient?” The expectation of surviving a resuscitation declines substantially after the age of 70. That fact is not a sole determinant for resuscitation, but it is an important factor.

Most importantly is the health of the patient and the reasonable expectation of whether or not a resuscitation effort would work. The procedure is very aggressive. Old age with its accompanying maladies (i.e., brittleness of the bones, frailty of health, etc.) could mean a painful and potentially futile resuscitation procedure. If other attending health conditions are poor it significantly reduces the potential of a success of a resuscitation procedure.

From the description you provide, it appears that in the event of a major organ failure it would NOT be reasonable to assume aggressive efforts to resuscitation would be successful. Because of the pain inflicted and high potential of doing more harm, I would not recommend a resuscitation procedure for him. In other words, I would place a DNR (do not resuscitation) order on him.

A decision regarding resuscitation is our effort to be a good steward of God’s blessing of life and to recognize his ultimate authority over life and death. A decision not to resuscitate represents our recognition that when a major organ failure occurs where an attempted resuscitation might occur, we feel all other indicators point to God calling him home. It is NOT a decision to end his life but rather an acknowledgment that based on all the things we know, there is not a reasonable expectation that an attempted resuscitation would be successful, but would only inflict more pain and suffering and perhaps even causing an earlier and more agonizing death.

What makes a feeding tube different than a DNR order is that a feeding tube generally does no harm. A resuscitation procedure could harm someone and agonize dying whereas a feeding tube is maintenance. It assures the body gets the needed nutrition while serving as an alternative to oral feeding which can, in the aging and infirm, possibly cause choking (aspiration) and a serious (potentially fatal) lung infection.

That being said, there is a time when even tube feeding should not be done any longer. That point is when the body refuses to process food or is unable to process food sufficiently. There are conflicting studies over whether this is the case in late-stage Alzheimer patients. My practical experience is that the most frequent time a decision is made not to tube-feed or to cease tube feeding is when a problem develops within the digestive system where an irreparable blockage may occur or for some other reason the stomach and colon stop functioning or malfunction in a way that continued feeding would agonize and possibly accelerate the dying process.

Sometimes there is a concern about whether a patient’s health could handle the procedure of installing a g-tube. While such a procedure is not “major” surgery, it is, nevertheless, some form of surgery and the concern often is whether the anesthesia becomes a problem. Those are issues to be weighed and, quite honestly, it becomes a judgment call. It is one thing to “insist” we do everything and “if they die, they die” but it is another thing to put this on the doctor who does the procedure. Generally speaking, no one wants to be the person causing death.

An alternative is a very pliable nasogastric tube (NG-tube) that is inserted through the nose and into the stomach. Some of the stiffer tubes are problematic but I cared for a woman more than 20 years ago with an NG-tube that was used for 3 years with no problems or agitation to the nose area. Staff, however, often is not excited about regularly changing the tube, but it did work.

Kind of a tricky way to find out whether it is possible to do this or not for your husband is to circumvent any bias the doctor has and ask these two questions:

1. If we did not insert a feeding tube how long would he continue to live?
2. If we inserted a feeding tube how long would he continue to live?

If the answer to question # 2 is longer than the answer to # 1, then it suggests placing a feeding tube (whether a G or NG-tube would need to be decided) is the route to go. Feeding tubes do not cure but sustain – as regular consumption of food does not cure but sustain. Because we have the means to continue providing such sustenance we do so if possible and not harming.

Again, my prayer for strength and comfort during this most difficult time.